Effect of dietary seaweed (Ascophyllum nodosum) supplementation on milk mineral concentrations, transfer efficiency, and hematological parameters in lactating Holstein cows

This study investigated the effect of feeding seaweed (Ascophyllum nodosum) to dairy cows on milk mineral concentrations, feed-to-milk mineral transfer efficiencies, and hematological parameters. Lactating Holstein cows (n = 46) were allocated to 1 of 2 diets (n = 23 each): (1) control (CON; without seaweed) and (2) seaweed (SWD; replacing 330 g/d of dried corn meal in CON with 330 g/d dried A. nodosum). All cows were fed the CON diet for 4 wk before the experiment (adaptation period), and animals were then fed the experimental diets for 9 wk. Samples included sequential 3-wk composite feed samples, a composite milk sample on the last day of each week, and a blood sample at the end of the study. Data were statistically analyzed using a linear mixed effects model with diet, week, and their interaction as fixed factors; cow (nested within diet) as a random factor; and data collected on the last day of the adaptation period as covariates. Feeding SWD increased milk concentrations of Mg (+6.6 mg/kg), P (+56 mg/kg), and I (+1,720 μg/kg). It also reduced transfer efficiency of Ca, Mg, P, K, Mn, and Zn, and increased transfer efficiency of Mo. Feeding SWD marginally reduced milk protein concentrations, whereas there was no effect of SWD feeding on cows' hematological parameters. Feeding A. nodosum increased milk I concentrations, which can be beneficial when feed I concentration is limited or in demographics or populations with increased risk of I deficiency (e.g., female adolescents, pregnant women, nursing mothers). However, care should also be taken when feeding SWD to dairy cows because, in the present study, milk I concentrations were particularly high and could result in I intakes that pose a health risk for children consuming milk.

Evaluating Person-Centred Integrated Care to People with Complex Chronic Conditions: Early Implementation Results of the ProPCC Programme

Introduction

The evaluation of integrated care programmes for high-need high-cost older people is a challenge. We aim to share the early implementation results of the ProPCC programme in the North-Barcelona metropolitan area, in Catalonia, Spain.

Methods

We analysed the intervention with retrospective data from May 2018 to December 2021 by describing the cohort complexity and by showing its 6-months pre-post impact on time spent at home and resources used: primary care visits, emergency department visits, hospital admissions and hospital stay.

Findings

264 cases were included (91% at home; 9% in nursing homes). 6-month pre vs. 6-months post results were (mean, p-value): primary care visits 8.2 vs. 11.5 (p < 0.05); emergency department visits 1.4 vs. 0.9 (p < 0.05); hospital admissions 0.7 vs. 0.5 (p < 0.05); hospital stay 12.8 vs. 7.9 days (p < 0.05). Time spent at home was 169.2 vs.174.2 days (p < 0.05).

Conclusion

Early implementation of the ProPCC programme results in an increase in time spent at home (up to 3%) and significant reductions in emergency department attendance (-37.2%) and hospital stays (-38.3%). The increased use of primary care resources is compensated by the hospital resources savings, with a result in the average total cost of -46.3%.

Viral dynamics in patients with monkeypox infection: a prospective cohort study in Spain

BACKGROUND

Monkeypox DNA has been detected in skin lesions, saliva, oropharynx, urine, semen, and stool of patients infected during the 2022 clade IIb outbreak; however, the viral dynamics within these compartments remain unknown. We aimed to characterise the viral load kinetics over time in various parts of the body.

METHODS

This was an observational, prospective, multicentre study of outpatients diagnosed with monkeypox in two hospitals and two sexual health clinics in Spain between June 28, 2022, and Sept 22, 2022. Men and women aged over 18 years were eligible if they reported having symptom onset within the previous 10 days of presentation, and were ineligible if disease was severe enough to be admitted to hospital. Samples were collected from five body locations (skin lesions, oropharynx, rectum, semen or vagina, and a dried blood spot) at six time points up to 57 days after the screening visit. Samples were analysed by quantitative PCR and a subset by cell culture. The primary endpoint was time from symptom onset to viral DNA clearance.

FINDINGS

Overall, 1663 samples were collected from 77 study participants. 75 (97%) participants were men, the median age was 35·0 years (IQR 29·0-46·0), and 39 (51%) participants were living with HIV. The median time from symptom onset to viral clearance was 25 days (95% CI 23-28) in the skin lesions, 16 days (13-19) in the oropharynx, 16 days (13-23) in the rectum, 13 days in semen (9-18), and 1 day in blood (0-5). The time from symptom onset to viral clearance for 90% of cases was 41 days (95% CI 34-47) in skin lesions and 39 days (27-56) in semen. The median viral load in skin lesions was 7·3 log₁₀ copies per mL (IQR 6·5-8·2) at baseline, compared with 4·6 log₁₀ copies per mL (2·9-5·8) in oropharyngeal samples, 5·0 log₁₀ copies per mL (2·9-7·5) in rectal samples, 3·5 log₁₀ copies per mL (2·9-4·7) in semen samples, and 4·0 log₁₀ copies per mL (4·0-4·0) in blood specimens. Replication-competent viruses were isolated in samples with high DNA levels (>6·5 log₁₀ copies per mL).

INTERPRETATION

In immunocompetent patients with mild monkeypox disease, PCR data alone would suggest a contact isolation period of 3 to 6 weeks but, based on detection of replication-competent virus, this time could be reduced. Based on findings from this cohort of patients, semen testing and prolonged use of condoms after recovery from monkeypox might not be necessary.

FUNDING

University Hospital Germans Trias i Pujol and the YoMeCorono.

TRANSLATION

For the Spanish translation of the abstract see Supplementary Materials section.

Evaluating the accuracy of self-collected swabs for the diagnosis of monkeypox

We evaluated the accuracy of patient-collected skin lesions, oropharyngeal, and rectal swabs amongst 50 individuals enrolled in a study of monkeypox viral dynamics. We found that the performance of self-collected samples was similar to that of physician-collected samples, suggesting that self-sampling is a reliable strategy for diagnosing monkeypox.

Kinetics of humoral immune response over 17 months of COVID-19 pandemic in a large cohort of healthcare workers in Spain: the ProHEpiC-19 study

Background

Understanding the immune response to the SARS-CoV-2 virus is critical for efficient monitoring and control strategies. The ProHEpic-19 cohort provides a fine-grained description of the kinetics of antibodies after SARS-CoV-2 infection with an exceptional resolution over 17 months.

Methods

We established a cohort of 769 healthcare workers including healthy and infected with SARS-CoV-2 in northern Barcelona to determine the kinetics of the IgM against the nucleocapsid (N) and the IgG against the N and spike (S) of SARS-CoV-2 in infected healthcare workers. The study period was from 5 May 2020 to 11 November 2021.We used non-linear mixed models to investigate the kinetics of IgG and IgM measured at nine time points over 17 months from the date of diagnosis. The model included factors of time, gender, and disease severity (asymptomatic, mild-moderate, severe-critical) to assess their effects and their interactions.

Findings

474 of the 769 participants (61.6%) became infected with SARS-CoV-2. Significant effects of gender and disease severity were found for the levels of all three antibodies. Median IgM(N) levels were already below the positivity threshold in patients with asymptomatic and mild-moderate disease at day 270 after the diagnosis, while IgG(N and S) levels remained positive at least until days 450 and 270, respectively. Kinetic modelling showed a general rise in both IgM(N) and IgG(N) levels up to day 30, followed by a decay with a rate depending on disease severity. IgG(S) levels remained relatively constant from day 15 over time.

Interpretation

IgM(N) and IgG(N, S) SARS-CoV-2 antibodies showed a heterogeneous kinetics over the 17 months. Only the IgG(S) showed a stable increase, and the levels and the kinetics of antibodies varied according to disease severity. The kinetics of IgM and IgG observed over a year also varied by clinical spectrum can be very useful for public health policies around vaccination criteria in adult population.

Funding

Regional Ministry of Health of the Generalitat de Catalunya (Call COVID19-PoC SLT16_04; NCT04885478).

Supplementary Information

The online version contains supplementary material available at 10.1186/s12879-022-07696-6.

Clinical presentation and virological assessment of confirmed human monkeypox virus cases in Spain: a prospective observational cohort study

BACKGROUND

In May, 2022, several European countries reported autochthonous cases of monkeypox, which rapidly spread globally. Early reports suggest atypical presentations. We aimed to investigate clinical and virological characteristics of cases of human monkeypox in Spain.

METHODS

This multicentre, prospective, observational cohort study was done in three sexual health clinics in Madrid and Barcelona, Spain. We enrolled all consecutive patients with laboratory-confirmed monkeypox from May 11 to June 29, 2022. Participants were offered lesion, anal, and oropharynx swabs for PCR testing. Participant data were collected by means of interviews conducted by dermatologists or specialists in sexually transmitted infections and were recorded using a standard case report form. Outcomes assessed in all participants with a confirmed diagnosis were demographics, smallpox vaccination, HIV status, exposure to someone with monkeypox, travel, mass gathering attendance, risk factors for sexually transmitted infections, sexual behaviour, signs and symptoms on first presentation, virological results at multiple body sites, co-infection with other sexually transmitted pathogens, and clinical outcomes 14 days after the initial presentation. Clinical outcomes were followed up until July 13, 2022.

FINDINGS

181 patients had a confirmed monkeypox diagnosis and were enrolled in the study. 166 (92%) identified as gay men, bisexual men, or other men who have sex with men (MSM) and 15 (8%) identified as heterosexual men or heterosexual women. Median age was 37·0 years (IQR 31·0-42·0). 32 (18%) patients reported previous smallpox vaccination, 72 (40%) were HIV-positive, eight (11%) had a CD4 cell count less than 500 cells per μL, and 31 (17%) were diagnosed with a concurrent sexually transmitted infection. Median incubation was 7·0 days (IQR 5·0-10·0). All participants presented with skin lesions; 141 (78%) participants had lesions in the anogenital region, and 78 (43%) in the oral and perioral region. 70 (39%) participants had complications requiring treatment: 45 (25%) had a proctitis, 19 (10%) had tonsillitis, 15 (8%) had penile oedema, six (3%) an abscess, and eight (4%) had an exanthem. Three (2%) patients required hospital admission. 178 (99%) of 180 swabs from skin lesions collected tested positive, as did 82 (70%) of 117 throat swabs. Viral load was higher in lesion swabs than in pharyngeal specimens (mean cycle threshold value 23 [SD 4] vs 32 [6], absolute difference 9 [95% CI 8-10]; p<0·0001). 108 (65%) of 166 MSM reported anal-receptive sex. MSM who engaged in anal-receptive sex presented with proctitis (41 [38%] of 108 vs four [7%] of 58, absolute difference 31% [95% CI 19-44]; p<0·0001) and systemic symptoms before the rash (67 [62%] vs 16 [28%], absolute difference 34% [28-62]; p<0·0001) more frequently than MSM who did not engage in anal-receptive sex. 18 (95%) of 19 participants with tonsillitis reported practising oral-receptive sex. The median time from onset of lesions to formation of a dry crust was 10 days (IQR 7-13).

INTERPRETATION

In our cohort, monkeypox caused genital, perianal, and oral lesions and complications including proctitis and tonsillitis. Because of the variability of presentations, clinicians should have a low threshold for suspicion of monkeypox. Lesion swabs showed the highest viral loads, which, combined with the history of sexual exposure and the distribution of lesions, suggests close contact is probably the dominant transmission route in the current outbreak.

FUNDING

None.

Efficacy of SARS-CoV-2 vaccination in patients with monoclonal gammopathies: A cross sectional study

SARS-CoV-2 vaccination is the most effective strategy to protect individuals with haematologic malignancies against severe COVID-19, while eliciting limited vaccine responses. We characterized the humoral responses following 3 mo after mRNA-based vaccines in individuals at different plasma-cell disease stages: monoclonal gammopathy of undetermined significance (MGUS), smoldering multiple myeloma (SMM), and multiple myeloma on first-line therapy (MM), compared with a healthy population. Plasma samples from uninfected MM patients showed lower SARS-CoV-2-specific antibody levels and neutralization capacity compared with MGUS, SMM, and healthy individuals. Importantly, COVID-19 recovered MM individuals presented significantly higher plasma neutralization capacity compared with their uninfected counterparts, highlighting that hybrid immunity elicit stronger immunity even in this immunocompromised population. No differences in the vaccine-induced humoral responses were observed between uninfected MGUS, SMM and healthy individuals. In conclusion, MGUS and SMM patients could be SARS-CoV-2 vaccinated following the vaccine recommendations for the general population, whereas a tailored monitoring of the vaccine-induced immune responses should be considered in uninfected MM patients.

Cetylpyridinium Chloride Mouthwash to Reduce Shedding of Infectious SARS-CoV-2: A Double-Blind Randomized Clinical Trial

The airborne transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) via respiratory fluids and droplets suggests that mouthwashes containing substances with virucidal activity can help reduce viral spread. We conducted a multicenter, double-blind, placebo-controlled, randomized trial to assess the virucidal activity of cetylpyridinium chloride (CPC) mouthwashes. Outpatients who tested positive for SARS-CoV-2 infection with or without symptoms were randomized to perform washes and gargles for 1 min with 15 mL of either colored distilled water or 0.07% CPC (Vitis CPC Protect) mouthwash. The study outcomes were the SARS-CoV-2 log₁₀ viral RNA load and the nucleocapsid protein levels, both in saliva at 1 and 3 h after the intervention. In total, 118 patients were enrolled and randomized (mean [SD], age 46 [14] y). Thirteen of 118 participants (11%) did not complete follow-up or had insufficient sample volume for testing and were excluded from the analysis. The assessment of the viral load showed no significant differences between groups at any of the investigated points. However, the levels of SARS-CoV-2 nucleocapsid protein of lysed viruses were significantly higher in the CPC group compared with the control group at 1 h (adjusted difference 269.3 pg/mL; 95% confidence interval [CI], 97.1-441.5) and at 3 h postintervention (561.1 pg/mL; 95% CI, 380.0-742.2). In nonhospitalized patients with asymptomatic or mild symptomatic SARS-CoV-2 infection, a 0.07% CPC mouthwash, compared to placebo, was associated with a significant increase of nucleocapsid protein levels in saliva, indicating enhanced disruption of viral particles.

Reduced humoral response 3 months following BNT162b2 vaccination in SARS-CoV-2 uninfected residents of long-term care facilities

Background

SARS-CoV-2 vaccination is the most effective strategy to protect older residents of long-term care facilities (LTCF) against severe COVID-19, but primary vaccine responses are less effective in older adults. Here, we characterised the humoral responses of institutionalised seniors 3 months after they had received the mRNA/BNT162b2 vaccine.

Methods

plasma levels of SARS-CoV-2-specific total IgG, IgM and IgA antibodies were measured before and 3 months after vaccination in older residents of LTCF. Neutralisation capacity was assessed in a pseudovirus neutralisation assay against the original WH1 and later B.1.617.2/Delta variants. A group of younger adults was used as a reference group.

Results

three months after vaccination, uninfected older adults presented reduced SARS-CoV-2-specific IgG levels and a significantly lower neutralisation capacity against the WH1 and Delta variants compared with vaccinated uninfected younger individuals. In contrast, COVID-19-recovered older adults showed significantly higher SARS-CoV-2-specific IgG levels after vaccination than their younger counterparts, whereas showing similar neutralisation activity against the WH1 virus and an increased neutralisation capacity against the Delta variant. Although, similarly to younger individuals, previously infected older adults elicit potent cross-reactive immune responses, higher quantities of SARS-CoV-2-specific IgG antibodies are required to reach the same neutralisation levels.

Conclusions

although hybrid immunity seems to be active in previously infected older adults 3 months after mRNA/BNT162b2 vaccination, humoral immune responses are diminished in COVID-19 uninfected but vaccinated older residents of LTCF. These results suggest that a vaccine booster dose should be prioritised for this particularly vulnerable population.

Transmission of COVID-19 in 282 clusters in Catalonia, Spain: a cohort study

BACKGROUND

Scarce data are available on what variables affect the risk of transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the development of symptomatic COVID-19, and, particularly, the relationship with viral load. We aimed to analyse data from linked index cases of COVID-19 and their contacts to explore factors associated with transmission of SARS-CoV-2.

METHODS

In this cohort study, patients were recruited as part of a randomised controlled trial done between March 17 and April 28, 2020, that aimed to assess if hydroxychloroquine reduced transmission of SARS-CoV-2. Patients with COVID-19 and their contacts were identified by use of the electronic registry of the Epidemiological Surveillance Emergency Service of Catalonia (Spain). Patients with COVID-19 included in our analysis were aged 18 years or older, not hospitalised, had quantitative PCR results available at baseline, had mild symptom onset within 5 days before enrolment, and had no reported symptoms of SARS-CoV-2 infections in their accommodation or workplace within the 14 days before enrolment. Contacts included were adults with a recent history of exposure and absence of COVID-19-like symptoms within the 7 days preceding enrolment. Viral load of contacts, measured by quantitative PCR from a nasopharyngeal swab, was assessed at enrolment, at day 14, and whenever the participant reported COVID-19-like symptoms. We assessed risk of transmission and developing symptomatic disease and incubation dynamics using regression analysis. We assessed the relationship of viral load and characteristics of cases (age, sex, number of days from reported symptom onset, and presence or absence of fever, cough, dyspnoea, rhinitis, and anosmia) and associations between risk of transmission and characteristics of the index case and contacts.

FINDINGS

We identified 314 patients with COVID-19, with 282 (90%) having at least one contact (753 contacts in total), resulting in 282 clusters. 90 (32%) of 282 clusters had at least one transmission event. The secondary attack rate was 17% (125 of 753 contacts), with a variation from 12% when the index case had a viral load lower than 1 × 10⁶ copies per mL to 24% when the index case had a viral load of 1 × 10¹⁰ copies per mL or higher (adjusted odds ratio per log₁₀ increase in viral load 1·3, 95% CI 1·1-1·5). Increased risk of transmission was also associated with household contact (3·0, 1·59-5·65) and age of the contact (per year: 1·02, 1·01-1·04). 449 contacts had a positive PCR result at baseline. 28 (6%) of 449 contacts had symptoms at the first visit. Of 421 contacts who were asymptomatic at the first visit, 181 (43%) developed symptomatic COVID-19, with a variation from approximately 38% in contacts with an initial viral load lower than 1 × 10⁷ copies per mL to greater than 66% for those with an initial viral load of 1 × 10¹⁰ copies per mL or higher (hazard ratio per log₁₀ increase in viral load 1·12, 95% CI 1·05-1·20; p=0·0006). Time to onset of symptomatic disease decreased from a median of 7 days (IQR 5-10) for individuals with an initial viral load lower than 1 × 10⁷ copies per mL to 6 days (4-8) for those with an initial viral load between 1 × 10⁷ and 1 × 10⁹ copies per mL, and 5 days (3-8) for those with an initial viral load higher than 1 × 10⁹ copies per mL.

INTERPRETATION

In our study, the viral load of index cases was a leading driver of SARS-CoV-2 transmission. The risk of symptomatic COVID-19 was strongly associated with the viral load of contacts at baseline and shortened the incubation time of COVID-19 in a dose-dependent manner.

FUNDING

YoMeCorono, Generalitat de Catalunya.

TRANSLATIONS

For the Catalan translation of the abstract see Supplementary Materials section.

A Cluster-Randomized Trial of Hydroxychloroquine for Prevention of Covid-19

BACKGROUND

Current strategies for preventing severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection are limited to nonpharmacologic interventions. Hydroxychloroquine has been proposed as a postexposure therapy to prevent coronavirus disease 2019 (Covid-19), but definitive evidence is lacking.

METHODS

We conducted an open-label, cluster-randomized trial involving asymptomatic contacts of patients with polymerase-chain-reaction (PCR)-confirmed Covid-19 in Catalonia, Spain. We randomly assigned clusters of contacts to the hydroxychloroquine group (which received the drug at a dose of 800 mg once, followed by 400 mg daily for 6 days) or to the usual-care group (which received no specific therapy). The primary outcome was PCR-confirmed, symptomatic Covid-19 within 14 days. The secondary outcome was SARS-CoV-2 infection, defined by symptoms compatible with Covid-19 or a positive PCR test regardless of symptoms. Adverse events were assessed for up to 28 days.

RESULTS

The analysis included 2314 healthy contacts of 672 index case patients with Covid-19 who were identified between March 17 and April 28, 2020. A total of 1116 contacts were randomly assigned to receive hydroxychloroquine and 1198 to receive usual care. Results were similar in the hydroxychloroquine and usual-care groups with respect to the incidence of PCR-confirmed, symptomatic Covid-19 (5.7% and 6.2%, respectively; risk ratio, 0.86 [95% confidence interval, 0.52 to 1.42]). In addition, hydroxychloroquine was not associated with a lower incidence of SARS-CoV-2 transmission than usual care (18.7% and 17.8%, respectively). The incidence of adverse events was higher in the hydroxychloroquine group than in the usual-care group (56.1% vs. 5.9%), but no treatment-related serious adverse events were reported.

CONCLUSIONS

Postexposure therapy with hydroxychloroquine did not prevent SARS-CoV-2 infection or symptomatic Covid-19 in healthy persons exposed to a PCR-positive case patient. (Funded by the crowdfunding campaign YoMeCorono and others; BCN-PEP-CoV2 ClinicalTrials.gov number, NCT04304053.).

Hydroxychloroquine for Early Treatment of Adults with Mild Covid-19: A Randomized-Controlled Trial

BACKGROUND

No therapeutics have yet been proven effective for the treatment of mild-illness caused by SARS-CoV-2. We aimed to determine whether early treatment with hydroxychloroquine (HCQ) would be more efficacious than no-treatment for outpatients with mild Covid-19.

METHODS

We conducted a multicenter, open label, randomized controlled trial in Catalonia (Spain) between March 17, and May 26, 2020. Eligible Covid-19 cases were non-hospitalized adult patients with recently confirmed SARS-CoV-2 infection and less than five days of symptoms. Patients were assigned to receive HCQ (800 mg on day 1, followed by 400 mg once daily for 6 days) or no antiviral treatment (not-placebo controlled). Study outcomes were the reduction of viral RNA load in nasopharyngeal swabs up to 7 days after treatment start, patient disease progression using the WHO scale up to 28 days, and time to complete resolution of symptoms. Adverse events were assessed up to 28 days.

RESULTS

A total of 293 patients were eligible for intention-to-treat analysis: 157 in the control arm and 136 in the intervention arm. The mean age was 41.6 years (SD 12.6), mean viral load at baseline was 7.90 (SD 1.82) Log₁₀ copies/mL, and median time from symptom onset to randomization was 3 days. No significant differences were found in the mean reduction of viral load at day 3 (-1.41 vs. -1.41 Log₁₀ copies/mL in the control and intervention arm, respectively; difference 0.01 [95% CI -0.28;0.29]) or at day 7 (-3.37 vs. -3.44; d –0.07 [-0.44;0.29]). This treatment regimen did not reduce risk of hospitalization (7.1%, control vs. 5.9%, intervention; RR 0.75 [0.32;1.77]) nor shortened the time to complete resolution of symptoms (12 days, control vs. 10 days, intervention; p = 0.38). No relevant treatment-related AEs were reported.

CONCLUSIONS

In patients with mild Covid-19, no benefit was observed with HCQ beyond the usual care.

The Cricotopus (Oliveiriella) (Diptera: Chironomidae) of the High Altitude Andean Streams, with Description of a New Species, C. (O.) rieradevallae

The genus Oliveiriella (Chironomidae, Orthocladiinae) was erected by Wiedenbrug & Fittkau (1997). The adults have characteristic black spots on their wings and other characteristics similar to the genus Cricotopus. Pupal skins are very characteristic with strong short spines in the anal lobe instead of setae, while larvae are distinguishable by the long anal papillae and the intense blue color of their body. However, Andersen et al (2013) consider Oliveiriella as a subgenera of Cricotopus. In this paper, using the sequences of the cox1 gene, we conclude that Oliveiriella should be considered a subgenus within Cricotopus, confirming its status in Andersen et al (2013). Furthermore, we describe Cricotopus (Oliveiriella) rieradevallae Prat & Paggi sp. n. from the Saltana river (Ecuador). The adult males, females, and preimaginal stages of the two species of subgenus Oliveiriella known from South America Cricotopus (O.) almeidai n. comb. from Peru, Brazil, and Argentina and Cricotopus (O.) sanjavieri n. comb. from Argentina are compared with those of Cricotopus (O.) rieradevallae sp. n. from Ecuador. The differences allow the distinction of the three species. The cox1 gene reveals that at least three different undescribed species of the same subgenus are present in the high-altitude tropical Andes. The morphology of the available pupae and pupal exuviae reveals the presence of several morphotypes that are candidates to be described as new species. A key used to distinguish these pupal morphotypes is provided, including the three described species. Additionally, the distribution of the subgenus is discussed.

Validating alternative methodologies to estimate the regime of temporary rivers when flow data are unavailable

Hydrological data for assessing the regime of temporary rivers are often non-existent or scarce. The scarcity of flow data makes impossible to characterize the hydrological regime of temporary streams and, in consequence, to select the correct periods and methods to determine their ecological status. This is why the TREHS software is being developed, in the framework of the LIFE Trivers project. It will help managers to implement adequately the European Water Framework Directive in this kind of water body. TREHS, using the methodology described in Gallart et al. (2012), defines six transient 'aquatic states', based on hydrological conditions representing different mesohabitats, for a given reach at a particular moment. Because of its qualitative nature, this approach allows using alternative methodologies to assess the regime of temporary rivers when there are no observed flow data. These methods, based on interviews and high-resolution aerial photographs, were tested for estimating the aquatic regime of temporary rivers. All the gauging stations (13) belonging to the Catalan Internal Catchments (NE Spain) with recurrent zero-flow periods were selected to validate this methodology. On the one hand, non-structured interviews were conducted with inhabitants of villages near the gauging stations. On the other hand, the historical series of available orthophotographs were examined. Flow records measured at the gauging stations were used to validate the alternative methods. Flow permanence in the reaches was estimated reasonably by the interviews and adequately by aerial photographs, when compared with the values estimated using daily flows. The degree of seasonality was assessed only roughly by the interviews. The recurrence of disconnected pools was not detected by flow records but was estimated with some divergences by the two methods. The combination of the two alternative methods allows substituting or complementing flow records, to be updated in the future through monitoring by professionals and citizens.

Least Disturbed Condition for European Mediterranean rivers

The present report describes a three-step approach that was used to characterize and define thresholds for the Least Disturbed Condition in Mediterranean streams of four different types, regarding organic pollution and nutrients, hydrological and morphological alterations, and land use. For this purpose, a common database composed of national reference sites (929 records) from seven countries, sampled for invertebrates, diatoms and macrophytes was used. The analyses of reference sites showed that small (catchment <100 km(2)) siliceous and non-siliceous streams were mainly affected by channelization, bank alteration and hydropeaking. Medium-sized siliceous rivers were the most affected by stressors: 25-43% of the samples showed at least slight alterations regarding channelization, connectivity, upstream dam influence, hydropeaking and degradation of riparian vegetation. Temporary streams were the least affected by hydromorphological changes, but they were nevertheless affected by alterations in riparian vegetation. There were no major differences between all permanent stream types regarding water quality, but temporary streams showed lower values for oxygenation (DO) and wider ranges for other variables, such as nitrates. A lower threshold value for DO (60%) was determined for this stream type and can be attributed to the streams' natural characteristics. For all other river types, common limits were found for the remaining variables (ammonium, nitrate, phosphate, total P, % of artificial areas, % of intensive and extensive agriculture, % of semi-natural areas in the catchment). These values were then used to select the list of reference sites. The biological communities were characterized, revealing the existence of nine groups of Mediterranean invertebrate communities, six for diatoms and five for macrophytes: each group was characterized by specific indicator taxa that highlighted the differences between groups.

Comparability of ecological quality boundaries in the Mediterranean basin using freshwater benthic invertebrates. Statistical options and implications

Within the Mediterranean region each country has its own assessment method based on aquatic macroinvertebrates. However, independently of the classification system, quality assessments should be comparable across members of the European Commission, which means, among others, that the boundaries between classes should not deviate significantly. Here we check for comparability between High-Good and Good-Moderate classifications, through the use of a common metric. Additionally, we discuss the influence of the conceptual and statistical approaches used to calculate a common boundary within the Mediterranean countries participating in the Intercalibration Exercise (e.g., using individual national type-boundaries, one value for each common type or an average boundary by country; weighted average, median) in the overall outcome. All methods, except for the IBMWP (the Iberian BMWP) when applied to temporary rivers, were highly correlated (0.82<R<0.98) with the common metric STAR-ICMi. This index was shown to respond well to a variety of pressures (especially local habitat alterations, riparian vegetation degradation, nutrient enrichment and chemical contamination, land use and global degradation; p<0.00001) affecting Mediterranean streams. However, depending on the statistical approach used, a different number of class boundaries failed the acceptable deviation from the common boundary (a quarter of class width). That leads to a different percentage of national sites failing to achieve good status and ultimately to a different technical and economic effort in the recovery of streams to that condition. We argue that low/high boundaries might have different meanings not restricted to the quality (good/bad) of reference conditions but also to the natural spatial and temporal variability contained in national and intercalibration types. The highly variable hydrological regimes of Mediterranean streams may influence the reference condition and require further investigation.

Distribution, Abundance and Molecular Analysis of Genus Barbadocladius Cranston & Krosch (Diptera, Chironomidae) in Tropical, High Altitude Andean Streams and Rivers

The distribution of the genus Barbadocladius Cranston & Krosch (Diptera: Chironomidae), previously reported from Chile to Bolivia, has extended northwards. Larvae, pupae and pupal exuviae of this genus have been found in the high mountain tropical streams of Peru to 9°22'56″, but are restricted to very high altitude streams (altitudes over 3,278 m asl) compared to the lower altitude streams (below 1,100 m asl) in which the genus is reported in Chile and Argentina. Based on morphological studies, both described species in the genus, Barbadocladius andinus Cranston & Krosch and Barbadocladius limay Cranston & Krosch, have been found in Peru as pupae or pupal exuviae. Morphological analysis of the larvae and pupae revealed no differences between the two described species from Patagonia and Peru, which are of similar size and with a similar armament of hooklets and spines in pupal tergites and sternites. However, molecular analysis of larvae and pupae revealed that in Peru, there are at least two different evolutionary lines, one distributed widely and another restricted to one site. Phylogenetic analysis (using cox1 mitochondrial sequences) of all available sequences of Barbadocladius shows that the Chilean and Argentinean material differs from that of Peru. Therefore, a total of four molecular segregates are identified, although morphologically, neither larvae nor the pupae may be differentiated.

Oviposition of aquatic insects in a tropical high altitude stream

The persistence of aquatic insect populations in streams depends on the recruitment of larval populations from egg masses deposited by adults, especially after disturbance. However, recruitment of aquatic populations by oviposition is a process that remains unstudied in streams and rivers. The objectives of our study were to document flying and oviposition patterns of aquatic insects in a high altitude tropical stream during both dry and wet seasons. In particular we studied 1) richness and abundance of adult forms of aquatic insects flying and ovipositing; 2) number of eggs (oviposition pattern), egg mass identity, and morphology; and 3) substrate preferences by ovipositing females. We found 2,383 aquatic insects corresponding to 28 families, with dipterans representing 89% of total individuals collected. Adult insects had lower richness (28 taxa) than larval diversity (up to 52 taxa) and distinct community composition. Richness and relative abundance of most taxa (adults) were not significantly different between seasons, behaviors, diel period, or all three. During both sampling periods we found females with eggs in a total of 15 different families (13 in the dry season and 14 in the wet season). There were no significant differences in the proportion of females with eggs between seasons, diel periods, or different behaviors (flying versus ovipositing traps) of the different female taxa. Few types of egg masses were found in rocks at the stream during both seasons, and most egg masses found corresponded to families Baetidae and Chironomidae. Finally, we provide the first description of eggs masses (size, shape, color, and number of eggs per female) of gravid females (10 taxa) and those found in the stream substrate (six taxa) of Andean macroinvertebrates. This is the first study reporting oviposition, adult diversity, and oviposition patterns of aquatic insects in the Andean region.

Release of polycyclic aromatic compounds into a Mediterranean creek (Catalonia, NE Spain) after a forest fire

Wildfires produce polycyclic aromatic compounds (PACs), among which polycyclic aromatic hydrocarbons (PAHs) are of environmental concern. After a fire affecting a Mediterranean creek, we studied the distribution and short-term permanence of PACs and of 16 priority PAH pollutants in the aquatic environment. PACs were traced through absorbance and fluorescence emissions and organic carbon concentrations. PAHs were analysed by gas chromatography. High TOC/DOC concentrations and fluorescence/absorbance values reflected abnormal inputs of fire-induced aromatic compounds. Their concentrations decreased gradually but showed sporadic peaks after precipitation. Fifteen months later, values still surpassed background levels. Initially concentrations of individual and total PAH species of the dissolved, particulate and sediment phases were increased. Then they fluctuated with new PAH inputs related with runoff, leaching and soil erosion following precipitation events. All PAH concentrations approached background levels 15 months after the fire, and never reached values of toxicological concern. However, some bioaccumulation may have occurred.

[Experiences of the Bavarian mammography screening program]

The Bavarian Mammography Screening Program started in April 2003. A detailed analysis of the consistency of diagnosis in the evaluation of vacuum-assisted stereotactic or core needle breast biopsies is presented. A total of 32 pathologists participated in a blinded evaluation of the biopsies. Each case was evaluated independently by two participating pathologists. A total of 1,357 cases were reviewed. The histopathological reports of the biopsies made by the two consulting pathologists were compared. The concordance rate of the first and second consulting pathologist was 93% for the B-classification. In general, the level of diagnostic agreement was very high for well defined, benign and malignant lesions. Some of the discrepancies resulted from the incorrect application of the B-classification. Discrepancies in the reports were also due to divergent interpretation of benign and "borderline" lesions. The protocol for the blinded evaluation of breast biopsies in two rounds assured a high level of quality. In conclusion, prerequisites for the success of a mammography screening program are interdisciplinary consensus conferences and audit rounds involving pathologists.

A critical review of guidelines for low back pain treatment

MAIN PROBLEM

Little is known about the methodological quality of guidelines for low back pain treatment. We evaluated the methods used by the developers according to established standards.

METHODS

PubMed, guideline databases, and the World Wide Web were used to identify guidelines. Seventeen guidelines met the inclusion criteria: interventions for low back pain stated, recommendations based on or explicitly linked to evidence, and English version available. Guidelines were evaluated independently by two appraisers using a practical tool for this purpose, Users' Guides to the Medical Literature, and the Appraisal of Guidelines for Research and Evaluation (AGREE) instrument.

RESULTS

Thirteen guidelines (76%) specified the most important therapies applied, but only nine (53%) included a complete description of the target population. Explicit processes to identify, select, and combine evidence were described in only six guidelines (35%). Few guidelines (3; 18%) explicitly considered all main outcomes when formulating therapeutic recommendations, and none contained a process to determine the relative value of different outcomes. Methodological criteria for grading the strength of the recommendations varied, and were often insufficiently specified. None of the guidelines assessed the impact of uncertainty associated with the evidence and values used. According to AGREE the quality score was highest for the scope and purpose, and clarity and presentation domains, and lowest for editorial independence and applicability. With regard to the recommendations, there was consensus for some of the interventions for acute pain (analgesics and NSAIDs, maintaining physical activity, and avoiding excessive bed rest), but explicit recommendations were lacking or ambiguous for 41% of the interventions. Most of the guidelines did not contemplate specific recommendations for chronic pain.

CONCLUSIONS

A small number of the available guidelines for low back pain treatment achieved acceptable results for specific quality criteria. In general, the methods to develop the guidelines' therapeutic recommendations need to be more rigorous, more explicit and better explained. In addition, greater importance should be placed on the recommendations for chronic pain.

Trace metal concentration, antioxidant enzyme activities and susceptibility to oxidative stress in the tricoptera larvae Hydropsyche exocellata from the Llobregat river basin (NE Spain)

Caddisfly larvae of Hydropsyche exocellata were sampled from seven locations receiving increasing levels of urban and industrial waste water discharges along the Llobregat river system (NE Spain) during spring and summer 2003. Locations were selected to include aquatic communities in poor and good ecological state according to measured physicochemical water parameters and the analysis of benthic macroinvertebtrate communities. Whole body residues of selected metals (Fe, Al, Zn, Cu, Co, Ni, Pb, Cd) were determined in conjunction with antioxidant enzyme activities (superoxide dismutase, SOD; catalase, CAT; glutathione peroxidase activity of GST, GSTPX), a phase II enzyme (glutathione-S-transferase, GST) and lipid peroxide levels measured as thiobarbituric reactive species (TBARs) with the aim of investigating whether resident macroinvertebrate benthic species were responsive to changes in water quality. Caddisfly larvae inhabiting those rivers were exposed to increasing levels of metal pollution. Enhanced activities of two (CAT and GST) out of the four tested enzymes, coupled with increased levels of TBARs, indicated increasing levels of stress in the studied species towards downstream reaches or locations near industrial and urban areas. These results indicate that combination of chemical and biochemical responses can be used to assess and diagnose pollution in high stressed river ecosystems.

Ecological profiles of caddisfly larvae in Mediterranean streams: implications for bioassessment methods

Caddisflies are a well represented group with high species diversity in Mediterranean climate rivers. Although they are widely used in water quality assessment, little is known of the ecological profiles of families or species. We present a simple score for ecological profiles which measures intolerance to water quality. The ecological profiles of caddisflies are diverse and the degree of tolerance at the family level is related to species diversity and the tolerance of individual species to water quality. Comparisons with the scores used in the biotic index IBMWP show general agreement between the degree of intolerance of a family and its score in the IBMWP, with few exceptions. Studies on tolerance are required to elucidate the autecology of taxa, and to develop biological indices, especially in areas with high species diversity.

Effect of dumping and cleaning activities on the aquatic ecosystems of the Guadiamar River following a toxic flood

The main aim of the study was to document the recovery of the aquatic ecosystem after the release of toxic mining waste in the Guadiamar River Basin (Sevilla, SW Spain) in April 1998. Samples of water, plankton, periphyton and macroinvertebrates were taken once a month at nine sampling stations (six affected by the toxic release and three for control). Water hardness and pH recovered in a few weeks and did not change significantly thereafter in the river or in the marsh stations. Only the Agrio River (the tributary that received the initial waste dump) had a low pH (3-5) throughout the study period. High ammonia contents (up to 300 microM) were measured at two sampling stations due to sewage and oil mill pollution. Eutrophication was also common at most of the stations, including one reference site. The planktonic community did not differ substantially between reference and affected stations. On all occasions the small phytoplankton and zooplankton (rotifers) were dominant. Compared with the reference station, chlorophyll a in the riverine area increased, especially in the sewage-affected stations, while in the marsh area, no significant differences were found between affected and reference stations. After 6 months of cleaning operations, in November 1998 the macroinvertebrate community of the river was composed mainly of species of short life cycles typical of ponds (Heteroptera, Coleoptera and Odonata), while typical riverine species found at the upstream control station had not recolonized the river due to the transformation of the river into a series of artificial ponds constructed as sediment traps. An analysis of variance showed significantly higher values (P < 0.05) for all heavy metals analysed (Zn, Cu, Pb, As, Cd, Sb, Tl) in plankton and macroinvertebrate communities from impacted sites. Values found in invertebrates were highly variable, with a mean concentration of the most abundant metals, Zn and Cu, between two and three times those found in unpolluted areas. Values for As were up to five times higher while Pb, Sb and Tl showed up to 10-fold increases. At the affected stations, the metal concentrations found in biofilms, plankton and particulate material were more than five times greater than those in invertebrates. The slow recovery of the aquatic ecosystem clearly reflected the impact of the metal discharge and the subsequent cleaning activities following the mine spill, as well as the sewage inputs at two of the stations studied.

Ovarian 17-hydroxyprogesterone hyperresponsiveness to gonadotropin-releasing hormone (GnRH) agonist challenge in women with polycystic ovary syndrome is not mediated by luteinizing hormone hypersecretion: evidence from GnRH agonist and human chorionic gonadotropin stimulation testing

Women with polycystic ovary syndrome (PCOS: hyperandrogenism and oligomenorrhea) have been shown to have exaggerated ovarian 17-hydroxyprogesterone (17-OHP) responses after GnRH agonist stimulation, suggestive of disordered ovarian cytochrome P450c17 alpha activity. However, most hyperandrogenic women also have an exaggerated LH response to both native GnRH and GnRH agonists. To assess whether the known LH hyperresponsiveness in PCOS patients mediates their exaggerated 17-OHP response to GnRH agonist challenge or whether the 17-OHP response can be duplicated by direct stimulation of the ovary with a fixed amount of hCG, 25 PCOS women [age, 20.6 +/- 1.1 yr; body mass index (BMI), 24.9 +/- 1.3 kg/m2] and 5 controls (age, 29.4 +/- 2.3 yr; BMI, 29.2 +/- 3.0) underwent both GnRH agonist (leuprolide acetate) and hCG testing. In addition, 23 normal women (age, 26.5 +/- 1.5 yr; BMI, 27.2 +/- 1.7 kg/m2) underwent hCG testing, and 21 other normal women (age, 19.3 +/- 0.5 yr; BMI, 23.0 +/- 0.8 kg/m2) underwent leuprolide acetate challenge. Blood was sampled before and 24 h after (the previously determined time of the peak response) leuprolide acetate (500 micrograms, sc) and hCG (5000 IU, im) stimulation tests. The tests were administered during the early follicular phase in women who were ovulatory and in randomized order in the subjects receiving both stimuli. Peak serum 17-OHP levels did not differ between leuprolide acetate or hCG stimulation in PCOS patients or controls when measured at 24 h (324.9 +/- 41.9 vs. 360.4 +/- 54.0 in PCOS; 183.2 +/- 19.6 vs. 141.2 +/- 11 ng/dL in controls). Peak 17-OHP levels after hCG challenge and GnRH agonist stimulation were highly correlated (r = 0.82; P < 0.001) in the subjects receiving both stimuli. Although leuprolide acetate elicited a higher estradiol (E2) response than hCG in all subjects, serum E2 levels increased significantly after hCG treatment in both patients and controls (P < 0.001 and P < 0.0001). The small, but significant, increase in serum E2 after hCG stimulation suggests that a rigid two-cell model of ovarian steroidogenesis may be an oversimplification of in vivo physiology. Our results suggest that exaggerated 17-OHP responses to GnRH agonist stimulation in hyperandrogenic women are not mediated by the known hyperresponsiveness of LH in these patients, but are due to increased ovarian androgen sensitivity to LH stimulation.

Hyperinsulinemia in postpubertal girls with a history of premature pubarche and functional ovarian hyperandrogenism

Previous studies have documented the association of insulin resistance and hyperandrogenism in adult women with functional ovarian hyperandrogenism (FOH) or polycystic ovary syndrome (a form of FOH). However, the possible impact of adrenal hyperandrogenism development during childhood in premature pubarche (PP) patients on postpubertal insulin secretion patterns remains unclear. The fasting insulin to glucose ratio, C peptide, early insulin response to glucose (IRG), mean blood glucose, mean serum insulin (MSI), glucose uptake rate in peripheral tissues (M), and insulin sensitivity indexes (SI) in response to a standard oral glucose tolerance test were evaluated in 13 PP girls with FOH (group A; age, 17.2 +/- 0.5 yr), 11 eumenorrheic nonhirsute PP girls (group B; age, 16.6 +/- 0.5 yr), and 21 age-matched controls (group C). Body mass indexes (BMI) were similar in the 3 groups (group A, 23.3 +/- 0.8; group B, 22.5 +/- 0.6; group C, 20.6 +/- 0.5 kg/m2). MSI values were significantly higher in FOH patients than in controls (74.7 +/- 17.6 vs. 45.7 +/- 4.1 mU/L; P < 0.01), but were not different from those in group B (63.3 +/- 11.1 mU/L). Thirty-eight percent of FOH patients (group A) and 27% of non-FOH patients (group B), all of whom had normal BMI, showed MSI levels well above the upper normal limit for controls (> 83.3 mU/L). MSI correlated with the degree of ovarian hyperandrogenism [defined by an abnormal 17-hydroxyprogesterone response to challenge with the GnRH analog leuprolide acetate; group A] and with the free androgen index [testosterone (nanomoles per L)/sex hormone-binding globulin (nanomoles per L) x 100; groups A and B)]. Although IRG, glucose uptake rate in peripheral tissues, mean blood glucose, and SI values were not significantly different in the 3 groups, 3 patients in group A and 1 patient in group B showed decreased insulin sensitivity and/or an enhanced early IRG. Among others, significant correlations between MSI and free androgen index values (r = 0.6; P < 0.002; groups A and B) and between BMI and SI (r = -0.53; P < 0.05; groups A and B) were found. Peak 17-hydroxyprogesterone responses to ACTH at PP diagnosis correlated positively with SI in both groups of patients (r = 0.53; P < 0.007). Hyperinsulinemia is a common feature in adolescent PP patients with FOH and appears to be directly related to the degree of androgen excess. Long term follow-up of PP patients into adulthood is warranted to ascertain whether hyperinsulinemia actually precedes FOH development and whether overt insulin resistance ensues.

Growth hormone, insulin-like growth factor-I axis, and insulin secretion in hyperandrogenic adolescents

OBJECTIVE

To assess GH and insulin-like growth factor I (IGF-I) axis variability in hyperandrogenic adolescents with different sources of androgen excess and their relationship with insulin resistance.

DESIGN

Baseline IGF-I, insulin-like growth factor binding protein-1 (IGFBP-1), IGFBP-3, GH response to the exercise-propranolol test, and insulin responses to a standard oral glucose tolerance test were compared among patients with functional ovarian hyperandrogenism, hyperandrogenic nonfunctional ovarian hyperandrogenism patients, and age-matched controls.

SETTING

Outpatient clinic in a medical center.

PATIENTS

Twenty-one adolescents with ovarian (group A) and 17 with nonovarian (group B) hyperandrogenism, and 20 controls.

RESULTS

Serum IGF-I and poststimulated GH levels were similar among groups, whereas serum IGFBP-3 levels were significantly lower in group A than in controls. Mean serum insulin levels were significantly higher in patients than in controls, whereas 24% of patients had abnormal insulin responses to glucose and/or insulin sensitivity indexes. Serum IGFBP-3 levels correlated negatively with the free androgen index (free androgen index = T/sex hormone-binding globulin [SHBG] x 100), whereas mean serum insulin levels correlated positively with the free androgen index and negatively with SHBG levels in all subjects.

CONCLUSIONS

Hyperinsulinemia is common in hyperandrogenic adolescents and correlates with the degree of hyperandrogenism and not with the androgen source. Hyperinsulinemia and decreased IGFBP-3 levels may enhance IGF-I bioavailability, which in turn may both decrease SHBG levels and increase androgen production.

Usefulness of an ACTH test in the diagnosis of nonclassical 21-hydroxylase deficiency among children presenting with premature pubarche

Adrenal steroidogenic function was evaluated in 55 children with typical premature pubarche (PP) to investigate the incidence of late-onset congenital adrenal hyperplasia (LOCAH) due to 21-hydroxylase (21-OH) deficiency and to evaluate the usefulness of routine ACTH testing in these patients. Four patients fulfilled criteria for LOCAH due to 21-OH deficiency. Of these, 3 had elevated baseline 17-OHP levels; in the remainder, basal 17-OHP was within normal limits. Mean basal and stimulated 17-OHP responses in children with PP, excluding those with an enzymatic defect, were very similar to those of controls (2.3 +/- 1.8 vs. 1.6 +/- 0.9 and 10.0 +/- 4.0 vs. 9.5 +/- 3.3 nmol/l, respectively). However, 5 patients had basal 17-OHP values exceeding the upper limit of controls and 8 patients, including 2 of those with elevated baseline levels, showed supranormal poststimulated 17-OHP values. Body mass indices, height standard deviation scores (SDS) and bone age SDS showed no correlation with the basal or incremental rises of any hormone. Four (7%) of our population of patients with typical PP had LOCAH due to 21-OH deficiency. Basal 17-OHP levels were helpful in detecting altered steroidogenesis in 3, thus suggesting that in some PP patients, LOCAH due to this enzymatic defect may remain undiagnosed if ACTH stimulation test is not routinely performed.

Source localization of androgen excess in adolescent girls

Functional ovarian hyperandrogenism (FOH) is characterized by an abnormal ovarian response to challenge with the GnRH analogs nafarelin and leuprolide acetate, similar to that observed in women with well defined polycystic ovary syndrome, regardless of whether elevated LH levels or polycystic ovaries are present. We studied an unselected group of 42 hyperandrogenic adolescents (age range, 14-22 yr; mean, 18.1 +/- 2.5 yr) 1) to determine FOH incidence through the assessment of ovarian-steroidogenic response to a single dose of leuprolide acetate, 2) to assess the clinical characteristics of patients according to their responses to GnRH analog stimulation, and 3) to evaluate adrenal steroidogenic function and its relation to ovarian hyperandrogenism in patients with either normal or abnormal responses to leuprolide acetate challenge. All patients underwent leuprolide acetate and ACTH testing, dexamethasone and ovarian suppression tests, and pelvic ultrasonography. Twenty-four (58%) patients had supranormal plasma 17-hydroxyprogesterone (17-OHP) responses to leuprolide acetate characteristic of FOH, and in 18, the 17-OHP response was similar to that of controls (n = 24; age, 17.1 +/- 2.3 yr). Seven patients (5 with FOH and 2 with normal responses to leuprolide acetate) had an abnormal response to ACTH, but only 1 had conclusive evidence of 21-hydroxylase deficiency. In 16 patients, the response to both stimulation tests was normal. Only 13 (54%) of the 24 FOH patients had polycystic ovaries on ultrasonography, and in 11 (46%), basal plasma LH levels were elevated. In FOH patients, reduction in testosterone and androstenedione plasma levels was significantly greater after ovarian suppression than after dexamethasone challenge (P < 0.0005 and P < 0.02, respectively). Peak plasma 17-OHP levels postleoprolide acetate simulation correlated with dexamethasone-suppressed plasma testosterone concentrations, dexamethasone-suppressed plasma androstenedione levels, and the free androgen index postdexamethasone treatment (r = 0.4, P = 0.01; r+ 0.4, P < 0.05; and r = 0.41, P = 0.007, respectively), Plasma sex hormone-binding globulin levels after dexamethasone administration correlated negatively with the baseline free androgen index (r = -.0.67; P < 0.0001). Considering our diagnostic criteria, 26 (62%) of our collective of 42 patients had abnormal responses to one or both stimulation tests, whereas 16 (37%) had normal response. FOH is the most common cause in (58%) of androgen excess in adolescence. Short term leuprolide acetate stimulation is a reliable tool fro identification of the ovary as the source of their hyperandrogenism.

[Pharyngo-gastric anastomosis following pharyngo-laryngo-esophagectomy for cancer]

Cancer of the hypopharynx and cervical esophagus usually presents in an advanced stage. Treatment is therefore aggressive and involves a combination of surgery and radiotherapy. Pharyngo-laryngo-esophagectomy, gastric pull-up and pharyngo-gastric anastomosis has become the method of choice for extensive tumors in the past decade. 3 men, aged 51, 51 and 74, respectively, who had extensive cancer of the hypopharynx and cervical esophagus and underwent this procedure are described. 2 made full, rapid recoveries without complications, but in the third, there were postoperative complications due to severe chronic lung disease. Proper selection of patients may reduce considerably the morbidity and mortality of this surgical procedure.